Dizziness - Symptom Evaluation

 

Dizziness is a common symptom for which a person visits a doctor. Balance is maintained by signals sent from the eyes, inner ears and the nervous system to the brain. Dizziness is of 4 main types, vertigo, disequilibrium, presyncope and lightheadedness. A careful history taking and examination by the doctor helps to differentiate between these four conditions.

When a patient complains of dizziness, the doctor will first enquire into the more common causes of dizziness. These include:

 Caffeine, nicotine and alcohol intake

 History of head and neck injuries

 History of anemia or low blood sugar levels

 Medication intake

Some medications result in dizziness by causing a fall in blood pressure. These include ACE inhibitors like enalapril, beta blockers like atenolol, diuretics like furosemide and nitrates like nitroglycerine. Medications that act on the brain like antipsychotics, opioids and anti-Parkinsonism drugs also cause dizziness. Sildenafil, the active ingredient of Viagra is also known to cause dizziness.

Some features accompanying dizziness that help to identify the cause are mentioned here. The individual causes are described in the next section.

 Episodic vertigo without hearing loss may indicate benign paroxysmal positional vertigo (BPPV)

 Episodic vertigo with hearing loss may be due to Meniere’s disease

 Episodic vertigo with symptoms of migraine may indicate migrainous vertigo

 Lightheadedness with excessively fast breathing may indicate hyperventilation syndrome

 A fall in blood pressure or an increase in pulse rate with a change in position may indicate orthostatic hypotension

 A shuffling gait with imbalance may indicate Parkinsonism

 A decrease in sensation in the lower limbs associated with dizziness especially feet may indicate peripheral neuropathy

 Vertigo preceded by a recent upper respiratory tract infection may be due to vestibular neuronitis or labyrinthitis


Some causes of dizziness are described below.

Dizziness is classified into the following 4 types:

Vertigo: Vertigo is the most common type of dizziness that people experience. The patients experience a false sense of motion, for example, they may complain that the room spins around them. Causes of vertigo are:

 Benign paroxysmal positional vertigo (BPPV): BPPV occurs due to the presence of small stones of calcium carbonate in the semicircular canals of the inner ear, which give a false sense of motion. The vertigo is episodic and is not accompanied by hearing loss. It is often accompanied by nausea and vomiting. The patient may experience a brief but intense episode of vertigo when he/she turns in bed at night or changes the head position. A test called the Dix-Hallpike maneuver is used to diagnose BPPV. During this test, the patient is in a seated position. The doctor turns the patient’s head 45 degrees to one side, then quickly puts the patient in lying down position with the head hanging about 20 degrees over the end of the table. The test is then repeated for the opposite side. Nystagmus or rapid involuntary movement of the eyes during the test is diagnostic of BPPV.

 Vestibular neuritis: A viral infection of the vestibular nerve results in vestibular neuritis. The patient usually does not suffer from hearing loss. The vertigo is persistent. Abnormal eye movements may be present.

 Labyrinthitis: Labyrinthitis or infection of the labyrinthine organs results in vertigo with hearing loss. The vertigo is persistent and may be preceded by a recent upper respiratory tract infection.

 Meniere disease: Meniere disease occurs due to increase in fluid pressure in the inner ear. It is usually accompanied by hearing loss and tinnitus (abnormal sounds in the ear) and occurs in episodes.

 Perilymph fistula: Perilymph fistula is a condition where there is leakage of inner ear fluid into the middle ear. It may be present from birth or develop following trauma like head injury, drastic changes in atmospheric pressure, physical exertion, ear surgery, or chronic ear infections. It results in unsteadiness when walking or standing that increases with activity and decreases with rest.

 Migrainous vertigo or vestibular migraine: Migraine can co-exist in patients with vestibular disease. Patients with are diagnosed with migrainous vertigo if they suffer from episodic migraine and in addition from migraine headache, photophobia, phonophobia or aura during at least two episodes of vertigo.

 Other central causes: Tumors, stroke or other conditions affecting the brain especially the areas involved in balance result in vertigo. These are more serious causes of vertigo. A patient with a central cause is severely unstable and cannot walk or stand without falling.

Disequilibrium: A patient with disequilibrium feels off balance and wobbly. In disequilibrium, the brain does not receive adequate information about the body’s position from the various senses like the eyes and inner ears. The reasons for imbalance could be:

 Stroke: A stroke is one of the reasons for imbalance. It is also accompanied by other symptoms of stroke.

 Poor vision: Poor vision can lead to imbalance, resulting in falls.

 Nerve and muscle related disorders: Other disorders that could cause imbalance are those that can affect nerves and muscles like Parkinson disease, peripheral neuropathy, and musculoskeletal disorders that may affect gait.

 Drugs acting on the brain: Drugs that act on the brain like benzodiazepines and tricyclic antidepressants can cause imbalance and falls especially in older individuals.

Presyncope: A patient with presyncope gets a feeling of losing consciousness or blacking out. Presyncope usually occurs due to a fall in blood pressure, often due to a heart-related cause. This results in reduced blood circulation to the brain and a feeling of dizziness. Causes of presyncope are:

 Abnormal heart rhythms like supraventricular tachycardias and heart attack. Cardiac tests may help to diagnose these conditions.

 Narrowing of the carotid artery (the artery that supplies blood to the brain). In addition, cervical spondylosis may also restrict the blood supply to the brain resulting in dizziness.

 Orthostatic hypotension: Blood pressure that falls with changes in posture is referred to as orthostatic hypotension. The blood pressure is recorded in lying down posture and then again in the standing posture. A fall in the systolic blood pressure of 30mm of Hg, diastolic blood pressure of 10mm of Hg or an increase in pulse of 30 beats per minute is indicative of orthostatic hypotension. A number of medications like reserpine, doxazosin and clonidine can cause orthostatic hypotension.

Lightheadedness: A patient with lightheadedness complains of vague symptoms like feeling disconnected with the environment. Causes of lightheadedness include:

 Psychiatric causes: Psychiatric causes like anxiety, depression and panic disorder can cause lightheadedness.

 Alcohol intoxication: Alcohol intoxication can also cause lightheadedness.

 Hyperventilation syndrome: Patients with hyperventilation syndrome breathe excessively fast. This may give rise to abnormalities in the pH of blood resulting in lightheadedness. The patient may suffer from additional symptoms like chest pain, paresthesias, bloating and pain over the stomach region.

 

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Heartburn - Symptom Evaluation

Heartburn

Heartburn is a symptom that occurs due to irritation of the food pipe either due to acid reflux or direct contact with spicy and irritant foods.

Heartburn is a burning and painful feeling in the chest just behind the chest-bone. In a normal person, the part where the food pipe meets the stomach is guarded by muscular valve called the lower esophageal sphincter. The sphincter ensures movement of food from the food pipe into the stomach, and at the same time prevents contents of the stomach from moving back into the food pipe. In some cases however, the tone of the lower esophageal sphincter may be reduced, allowing the acidic contents of the stomach to move back into the food pipe. This results in symptoms of heartburn. Heartburn may also occur due to direct irritation of the food pipe. The pain of heartburn typically appears after a meal and is increased if the person lies down soon after the meal. Patients with reflux symptoms usually experience heartburn at least twice a week.

On long term, reflux can cause complications including cancer of the food pipe in some individuals. Reflux not only causes inflammation of the food pipe; the acid may reflux into the respiratory tract resulting in cough, laryngitis (inflammation of the sound box), pharyngitis (inflammation of the upper throat), sinusitis (inflammation of the sinuses) and lung complications like bronchitis, asthma, and pneumonia.

The cause of heartburn is usually obvious in each case. Once heartburn is diagnosed, it is important to treat it early to prevent complications.

Some causes of heartburn are listed below:

Substances that irritate the food pipe:

Substances like spicy foods, citrus fruits, cigarette smoke and aspirin-like painkillers that irritate the food pipe can result in heartburn. Decreased lower esophageal sphincter tone:  In many cases, the cause of decreased tone of the lower esophageal sphincter is not known. In other cases, it may be due to:

 Intake of certain foods and beverages: Certain foods and beverages like peppermint, caffeinated drinks like coffee, tea, and soft drinks, chocolate, fatty foods, and alcohol decrease the tone of the lower esophageal sphincter resulting in reflux and heartburn.

 Scleroderma: Patients with autoimmune conditions like scleroderma may have a decreased lower esophageal sphincter tone resulting in reflux.

 Smoking: In addition to acting as an irritant, smoking also decreases lower esophageal sphincter tone leading to reflux.

 Medications: Some medications like anticholinergic drugs and smooth muscle relaxants relax the lower esophageal tone and result in reflux.

 Surgery: Damage to the lower esophageal sphincter due to surgery can decrease the tone of the lower esophageal sphincter.

Conditions where the gastric contents are near the gastroesophageal junction: This happens in the following situations:

 While lying or bending down: Contents of the stomach tend to move backwards into the food pipe when a person lies or bends down especially soon after a meal.

 Hiatus hernia: Hiatus hernia is a condition where a part of the stomach moves up into the chest due to weakness in the diaphragm (the muscular partition between the chest and the abdomen). Symptoms may be more obvious in conditions like pregnancy where the pressure on the stomach is increased.

Conditions where pressure in the stomach is increased: The pressure on the stomach is increased in conditions where the intraabdominal pressure is high. This is seen in conditions like obesity, pregnancy, ascitis (accumulation of fluid in the abdomen) and wearing tight clothes.

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ACIDITY

What is ACIDITY ?

The stomach normally secretes acid that is essential in the digestive process. This acid helps in breaking down the food during digestion. When there is excess production of acid by the gastric glands of the stomach, it results in the condition known as acidity. Dyspepsia, heartburn and the formation of ulcers are some of the symptoms. It is more common in highly emotional and nervous individuals.

Common Causes of Acidity

Consumption of Alcohol
Highly spicy foodstuffs
Non-vegetarian diets
Non-Steroidal Anti-Inflammatory Drugs (NSAID's)


Most acidity problems occur

After meals
When lifting weight or straining and applying pressure in the intra-abdominal area.
At night when lying down.
Ulcers also occur as a result of over secretion of acid.


Home Remedies for Acidity
 

After all three meals, take a small piece of jaggery and keep it in your mouth and suck. Voilá no more acidity.

Boil one cup of water. To this add 1 tsp of Aniseed (Saunf). Cover and leave overnight. Strain the water in the morning, add 1 tsp of honey. When this is taken 3 times a day it prevents acidity.

To 1 ½ liters of water add 1 tsp Caraway seeds (shah jeera). Bring to a boil and simmer for 15 minutes. Sip while warm. Have the concoction 2-3 times a day for 5-6 days.

Powder one clove and one cardamom; use the powder as a mouth freshener after every meal. No more acidity and no more bad breath.

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Anemia / Low Haemoglobin

 Anemia / Low Haemoglobin

RBCs in the blood have a very crucial role to play as they contain hemoglobin, which carries oxygen to the body tissues. Anemia leads to a host of health complications as body tissues are deprived of the required amount of oxygen to keep them healthy. Thus, victims of anemia often complain of extreme fatigue.

General malaise, weakness, fatigue, breathlessness on exertion, palpitations, and angina are some of the symptoms of anemia.

Anemia can be caused due to nutritional deficiencies, especially iron and vitamin deficiency. Inherited disorders also cause anemia. Exposure to a particular drug or toxin, and certain kinds of cancer also cause anemia. Anemia can set in either due to abnormal loss of blood, or insufficient production of RBCs or when RBCs are destroyed due to an existing medical condition.

Anemia is diagnosed after conducting a complete blood cell (CBC) count, which examines the different types of cells in the blood.

Treatment for anemia is targeted towards the cause of the condition and its outcome depends upon the cause, extent of the condition and general health of the patient. Generally, the prognosis is good for victims of anemia.

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